RehaCom: an introduction to a new tool for cognitive rehabilitation

– [Speaker] Good afternoon,
everybody, on the East Coast, and good morning to those of you who are joining us from
other parts of the States. I do know some of you are in
California, and so welcome, and thank you for taking time out of your busy schedules to join us today. My colleague, Dr. Shinaver, helped to develop these slides and this PowerPoint presentation, and he was unable to be with us today, but my other colleague,
Dr. Anne-Marie Kimbell, will be able to be in the chat box and answer any questions
that you may have. So welcome. First of all, I do want to give you a little introduction about myself. Like many of you, I have, at some point, worked in a rehabilitation setting. I was at a rehab hospital, just outside of Boston, for six years, primarily working with pediatrics, but I did have the opportunity to see some of the inpatients
at Braintree Hospital, and also to participate in some of the teaching
webinars and presentations and seminars that we have there. And for some of you, that’s
a very well-known facility, and for those of you who
are less familiar with it, just to give you a sense, we did have aphasia
rounds with such people as Harold Goodgrass and Edith Kaplan, along with our own
neurologist Mick Alexander and Doug Katz. And for those of you who
are familiar with Doug Katz, who’s a adult urologist, he is also the current president of the American College of Rehab Medicine and they have a conference
next week in Atlanta and I shall be presenting there. So welcome everybody and I hope you find this presentation on RehaCom of interest. Our agenda today is as follows. We will look at the subject of computerized cognitive training, why cognitive training, and
what is the background to it. I will explain that in some detail. We also will look at the different client and patient populations that can be served by the RehaCom program. And the role that clinicians play in monitoring and supervising the implementation of this program. We’ll look at different
distinctive features and how to screen patients. We’ll also look at the training modules that are available with this program that involve attention, memory, executive function, and visual field, It can be used, not just
to assess individuals, but also to provide
therapy, and as a result, you’ll be able to see how you can extract data about their results. We’ll briefly review
research on this program, as well as how to operate it, and we will summarize and conclude. The first thing I would
like you to all know is that the RehaCom program came from a group in Magdeburg, Germany, from HASOMED, and they created this
program almost 25 years ago. It was developed primarily for clinicians. So when you think about
where did it come from? How long has it been around? What’s the background to it? The answer is it came to us from Germany. From the outside, it was a computerized cognitive training program and they decided that there
were different areas of training that were really going to
be important to focus on. Visual field. One of the points I would
like to make here is that when I went to a conference, actually at North Carolina, with a group of athletic trainers and we were discussing
head injury and concussion in student-athletes, a neurologist who presented said one of the overlooked
areas for individuals that sustained a concussion or a more severe type of head injury is a visual field neglect, and so this program does offer both a screening as well as
treatment and programming for individuals that may have problems with their visual field. What is curious, as you may know, is that people may be unaware that they do not have a good visual field, they may be able to see very well on one side of their visual field but not so well on the other. We’ll look at the whole
subject of attention, as well as memory and working memory, and what we do know is that
there are many individuals that will sustain a head injury, or who may have had stroke, or perhaps a degenerative disorder, that will experience an attention problem and possibly a memory problem too. So these are very common disorders. We’ll also look at the
area of executive function and you’ll be able to see then that the program will screen for that, as well as provide 22 configurable training modules. One of the features
that I will expand upon is that the program does auto-adapt to the ability
or level of the patient. Also, for some patients who are impatient, you may find it has a
very low level of training because some patients have a
very severe cognitive deficit and they do require a very easy level to be able to commence this program. I did speak to some
therapist one time who said, “Oh no, this program’s too
hard for our patients,” unaware that you can start
at a much lower level than where they were. So it can be done with patients who have only
recently been admitted to hospitals with a head injury and some of the early research was really based on
that patient population. So, who are the patients? What clients would benefit from this? So, who can it be used with? If you have patients that
have cognitive deficits, they may be as a result of degenerative neurological disorders. For example, multiple sclerosis. It may be that the patients
had some kind of a brain injury of a traumatic nature, they may have had a CVA or stroke, or some other clinical
condition that impacts cognitive function in an adverse way. Now, what you may find
is that the deficits of those patients may range. They may be mild, or
they may be more severe, and you can use the
program with a wide range. Now I was talking to one hospital and the staff said you have to understand that we have a lot of college professors, we have physicians, lawyers, professionals who have been the subject of either a
head injury or a stroke, and for them, we need to have a program that will be challenging, and perhaps won’t be
typical of other patients, and so it really does
range, and you will see, as you look through the program, that it can be very challenging, even for those who have not
had any kind of an injury. Now, what kind of
training can be provided? It may be able to restore or compensate for the type of injury or insult that the patient’s experienced, and as a result, it may be
very helpful to that patient and their family. Typically, these clients
will work in a clinic, hospital setting, and often is
in a rehabilitation setting, particularly in the
United States and Canada. Now, it would be important to note that in some of the
countries, like Germany, some patients are able to do work at home, but in the United States, currently it is configured so that it would be part
of either an inpatient or an outpatient rehabilitation center where it could be properly
monitored by clinicians. So who would actually delivery RehaCom? The answer is it is clinician-mediated, it can only be accessed if
you have a clinician engaged. So, we don’t sell directly to the public, this is not something
that can be done at home by a family just because that’s convenient and they just want to
be able to access it. It has to be mediated by somebody
who’s properly qualified. What are those current processes that you are currently using? Do you have patients that
have deficits in attention, working memory, visual scanning,
or executive functions? Chances are that’s a relevant population for their RehaCom program. Some of these individuals may
be children or adolescents, they may be adults or even older adults, and when you think about
problems with attention, of course that’s both
auditory as well as visual, and when you think about visual scanning, we’re referring to do they
see their entire visual field or just one part of it? And do they have trouble
formulating plans, prioritizing, organizing,
coping with the demands that we would consider
executive functioning? Do you have patients that
have degenerative disorders? In many rehab facilities,
that is the case, that although they may
not be formally diagnosed, we know that many of them
will come into the facility with a disorder which may
then become more extreme as we get to know them or perhaps as they deteriorate over time. We may also see that
they have an acute onset, perhaps a stroke or a TBI, and we may even find they
have other conditions such as an attention deficit. Certainly, children, adolescents that have an attention problem may be diagnosed as ADHD, but even if they don’t
have an attention problem, they may still experience
problems with their working memory and executive function and
they may be diagnosed ADHD. So, this is a program that may
be quite helpful to them too. However, that’s not all. We’re not just talking about
patients that may be seen by neurologists, these
are patients that may also benefit from the program, and I have occasionally
talked to clinicians who said I just see
schizophrenic patients, I only see individuals
in a hospital setting that have a psychotic disorder, and I can share with you
that the first eight years of my experience in the Waltham area was working with individuals that
were diagnosed psychotic, and in some cases, schizophrenic, and I can completely
understand why you would want to have a program
that could help them. Of course, what we know is that sometimes there’s a combination of disorders and some of the researchers
even explored that. One of the articles on
RehaCom looked at individuals, particularly adolescents and
children that had had both brain injury and ADHD, so
sometimes there’s a combination. Now, there are disorders
in attention and memory but we may see some patients
struggle with the visual field and many patients that have
attention and memory problems also experience executive dysfunction. But not just that, we also see, sometimes, a reaction to neurological problems, such as depression and anxiety. I know there are often
times when a person’s had an acquired brain injury and
they may become quite depressed and anxious about their
performance as a result. One of the symptoms or sequelae would be that they react to their
disorder in this way. But we also realize that
sometimes individuals may present with depression, unaware that there may
be some neurological or degenerative disorder
associated with them. I’ve sometimes seen that elderly patients, they go on to exhibit
mild cognitive impairment and sometimes Alzheimer’s, dementia, may present initially
as having depression. So the question might be is
it relevant to individuals whose primary symptoms appear
to be depression and anxiety, and the answer is it can
be helpful to them too. So it is clinician-mediated. We don’t sell it to the public, we do think it’s important for
the public to know about this but this was decided a long time ago, that clinicians needed a
computerized cognitive program to assist their patients,
it was developed for them from the very beginning. So why does this all matter? The simple answer is fidelity. We want to make sure that individuals that do have a diagnosed
disorder get help, and what we know is that
if it’s self-administered, there’s a tendency not to finish. Adults frequently have lots of reasons why they’re unable to complete a program, and they may be very good
reasons on the face of it, for example jury duty, or
perhaps planning a wedding, or perhaps there’s been
a death in the family and they have to put everything aside, but what we also know is that sometimes we give ourselves excuses to allow us not to complete some program that is very challenging
and perhaps hard work. So there’s a problem with fidelity. Did you do what you needed to do over the time period that was required, and the answer is often no. That alliance, however,
the clinicians have, can be very helpful. We know that there is
a therapeutic alliance, the clinicians, whether it’s
an OT, a PT, a psychologist, a physician, may have with their patients is very important. That facilitates engagement
and it allows the person then to do the computerized cognitive training knowing that someone is
watching, that they care, that they want the patient to do well, and they’re encouraging
them to persist at it. We also want the relationship to take into account that
the cognitive training may be in the context of
a more severe disorder. So is that all you need? Is it sufficient? Is that enough? And the answer is no. Individuals listening to this webinar must realize this is perhaps
a piece of the puzzle, it’s not viewed as a standalone treatment, and we are not arguing that. When I went to one hospital, they said, well I guess you don’t need us, this is just a standalone and the speech or OT don’t
need to be involved, and the answer is that’s not true at all. Expertise by experienced
and empathic clinicians is vital to ensure that the program is managed and that there’s
oversight to the process. So, what we’re saying
is this is a component of what you can offer to your patients, it is not sufficient but
your role is necessary. Also, it allows you to be
able to automate some elements and it may create both
efficiency and efficacy. We’re not adding to your time, rather, what we may find is
that we can help you do your job and save some time, particularly in such things as note-taking or record keeping or
the ability to monitor a patient’s performance. So by automating some of those elements, you then can be freed up to do other tasks and it allows you to become
efficient as clinicians. Also accessibility because as more time and
opportunity become available, there are different aspects of
overall treatment management that allow you to be engaged and to be able to perform your job. So disorders like a
traumatic brain injury, stroke, acquired brain injury that require a comprehensive approach may include physical therapy. I had a young man once who was hit in a motor vehicle accident and he required very
intensive physical therapy when he was on an inpatient basis and he continued to require
it as he went back to school and he needed the therapy
in order to be able to become more independent
and self-sufficient, and we know physical therapy can be wonderful for a lot of patients. Also, that’s my view about
occupational therapy. I think of OT as a wonderful tool for individuals that have had
different types of disorders in that it enables them to
accomplish different tasks. Psychiatry may be involved, particularly when it comes
to medication management, as well as speech and language therapy. Particularly, in such things as recognizing how language and pragmatic language, in particular, may change as a result. I know one time that I had an adult referred to me because what he wanted to
say and how it came across was sometimes very different than the experience that
his family members had and he didn’t understand how he was aggravating, frustrating others, and it made him more
labile and he would tend to have a very short fuse, and consequently, he would provoke arguments, unaware that it was his own interaction that led to some of
that difficulty, and so, for many patients, speech
therapy is really an urgent and important part of their treatment. So treatment does require
a comprehensive approach, and in any one particular case, there may be a variety
of different clinicians, and consequently, any one of
those may become the mediator for the RehaCom program. This is a program that
is used a great deal in Europe, by OTs. It can also be used by speech
and language therapists because there are parts of the program that may be very appealing
to them, and again, when I presented this in hospitals, the speech language therapist
seemed to be on board before some of the
others around the table. They’ve heard about this,
they know they want this, this is going to enable them
to accomplish certain tasks and they see the value
and I appreciate that. Psychologists, and again,
neuropsychologist may play a role and I think it’s important to recognize that in places such as Germany, or for that matter, the UK, the psychologist may play a very different and a pivotal role than they may in some hospitals in the States. So for example, in Germany, it might be the neuropsychologist that will consult with the physicians, particularly after a patient’s
had an MRI or a CT scan and other work done, and
they may then determine what types of programs may
be appropriate for patients, who’s gonna provide some of those, and so they may play
that role of mediating, monitoring, and overseeing
service delivery in an inpatient setting, and one of our clinicians in Germany was sharing with me, he’s done
this for the last 20 years, and he has seen several hundred patients where the RehaCom program
has been provided, and then he has his own
insights and observations about how he can adjust the demands, and let’s say, the parameters of
the program for his patients. In the States, we may also
have physiatrists involved, and physical therapists,
as I said earlier, physicians generally, and
other important clinical staff can all play a role in mediating the implementation of this program. Now, what makes it different
and why does this matter? Well, the program was initially
developed 25 years ago by a psychologist in
Germany called Dr. Weber, and his colleagues at different
hospitals and facilities, and since that time has
been updated and revised. This was a tool developed for clinicians, and so when they were
frustrated by something or they needed to see something improved or changed or expanded upon, that feedback was incorporated and other components were developed. So it’s reflected in the
range of training areas, in the breadth of training
that is currently available, and how it can be configured, and so, we wanted to let you
know that its relevance has really been tested over
that quarter century in Europe and we can now benefit from the fact that clinicians have been involved from day one saying this is what I want to see changed, and if you can incorporate that, it may be more useful to me. So there are a broad
range of training areas, this is not just a program that looks at one distinctive thing
such as working memory. It explores areas that are
important for patient care, such as attention, executive functioning, and visual scanning which
may otherwise be overlooked. So its breadth is important
and it has the range. Now, it also has a breadth
in terms of very low levels for the severely impaired patients, to rather difficult levels for those with much milder problems. So if you had an adult that may have been at a very high professional
level in their career, who’s experienced some
reduction in their efficiency, you may still be able to
challenge them and work with them because it will challenge
even the brightest amongst us. The other thing to be aware
of is that there are ways in which you can change the
trainings being offered. Now, I understand, from
clinicians in Germany, that a lot of times OTs
would just leave it as is and that reminds me a little
bit of a Mercedes car, where you can have it in automatic and you don’t need to worry
about what gear am I in, unless you wanna go
backwards or just park, and if you rely on the
automatic feature of the car, you’ve been doing quite nicely, and so some of the programs
are just like that. They are auto-adapted and they are configured
by the computer for you. However, you may also decide
I wanna get out of that automatic approach and I
wanna be able to change some of the parameters, I want to refine the treatment, I wanna prioritize different areas, I am gonna make it harder. So for example, you might say, I wanna take out language
that involves instruction, or I don’t wanna have to repeat the instructions over and over, and I wanna take out the cues, so that when they get it wrong, I don’t want them to know that. So, or let’s exchange the exposure time. So in a way, when you’re moving away, from a more auto adaptive version to a more refined specific version, that’s something that the psychologists and neuropsychologists, those clinicians seem to
prefer to do in Germany because then they can really understand what they’re asking their patients to do and adjust the demands
that are confronting them. So it is configurable. Now, what is the offer? The answer is you can screen. You can screen in different ways and you can get a baseline measure. You can also see if that’s
where the patient is today, that’s a reference point
that we can then use to guide our training and we can see what screening modules might be needed, what additional assessments
might be needed, or what other therapies
might be appropriate. So it allows us to figure
out where should we begin. Let’s say the patient presents as having an attention
problem, how bad is that? What does it apply to? What kinds of tasks does the
patient have a problem with? And we can figure that out. Also, the program will adjust according to the performance of the patient. So by using live feedback, it will semi-autonomously figure out what the
training levels should be, and as I said before, you the
clinician, can change that. Well often, it’s been
found that therapists like to have the computer determine what the difficulty level should be. It’s less work and it’s not
something they want to do. And lastly, reports can be provided, and this includes graphs
and numerical data, and those objective data
can then be exported, printed, and entered into medical records so that it allows you
to then be able to say, this is what the
patient’s been working on, this is how they’re doing and you can then see this
is how they did today, this is how they compare
with previous days, this is my goal and this is how far they are in achieving that goal. So it is all too adaptive and it’s individualized
to the particular patient that you have. What does that do? Well, it makes the training effective and easier to tolerate, the patient doesn’t feel, like, I’m frustrated because
I’m not getting where, I can’t do this, this is too hard. What it does instead it makes it easier, and then, day to day,
as the patients change, perhaps there’s good days and bad days, the program can adjust as well. You can decide where you want to start and you can then be flexible. So there’s a range of options
that are offered to you, the clinician, to then decide. Where do I begin? It also allows you, as I said earlier, to be more effective and
perhaps more efficient. So those lower levels of training that are really important to patients that have severe deficits, it could be helpful for them to start. And I know it can be so frustrating for family members and loved ones to say there’s nothing that can be done for my son, daughter, husband, wife, relative because they are so severely injured, nothing is gonna be helpful, and the answer is this does
go down to a pretty easy level and it was determined
that patients that are more severely impaired also need to have shorter periods of time per training, perhaps more frequent, so they may have two or three a day, and then they do what they can manage and they will build up their energy level or their ability to tolerate
fatigue and attention. However, for some patients, you need things that are challenging and it does offer that, so there’s a broad range. And we do suggest, try
the program out yourself. Now, one of the things to also be aware of is that there is a unique keyboard, which is provided through RehaCom, that makes the tasks much easier. So you don’t need to get the keyboard, however, it was designed
to make the training and the screening much easier for them, and this is available through
us in the United States, if you so desire. So you can press the Okay button, there are right and left buttons, and let’s say you have a
patient that is a dyspraxia, they have a dysarthria and
they’re having trouble, well this might be ideal for them. Some patients don’t need it, that’s fine, but I can tell you it
makes the task performance so much easier when you use the keyboard, which has a accessibility to a broad range of patients and it also has a little
USB port on the underside, which will plug into your computer. So, there are screening programs, as you can see below. In the area of attention, there are such things
as alertness, vigilance, spatial, selective, and divided attention, and visual attention. And so as you look at those
modules, you might decide, okay, this patient seems to be
at a pretty low level, so I’ll start with
attention and concentration. So screening is a very
good place to start. You can identify what the deficits are for a particular patient and
that’s gonna guide what you do. Then, the training is flexible and you can start with any module. This program does not determine for you what you should be doing, however, it will provide what you
may want to focus on. And some areas that say there’s
a problem with alertness and attention, you may
need to start there. Also, it allows the clinicians
to approach the training as they see fit, what do they think needs
to be accomplished? So there are 22 training modules, once the screening has begun. The same principles and the structure apply to all those modules and it does allow the training to be faster and more intuitive. Let’s review the screening modules. On the left-hand side, you can see the module name, and on the right-hand
side, what does it do. So, in the area of attention,
you’re looking at alertness. Does the patient react? How responsive are they? And it will measure such
things as how quick they are, how long do they take. Can you pay attention to the stimuli that have been selected? And can you divide attention
between different tasks? Can you also visually scan
and find certain numbers? And can you selectively
attend as you’re doing that? So those are attention screeners. In the area of memory,
you’re looking at words and working memory, and working memory is defined as not just the registration and repetition
of auditory or visual input, but rather, the ability to problem-solve, take into account items
that may have had to be held in memory for a short period of time. So, it’s not just recall,
it’s using stimuli to actually problem-solve. We have got logical reasoning, and then in the visual field, does the person scan, can
they see the entire screen? And as a result, they might
require saccadic training. Also visual field. Now, I spoke to an ophthalmologist
recently about this and he said, “The way I defined saccadic “eye movement training would be “the ability to form a
three-dimensional image “by moving the eye or perhaps the head, “to be able to consolidate visual data,” and you’ll see that when you
do the saccadic eye training on the RehaCom program, that there are different components that are being identified. So these are the screening modules. You are looking at tonic
and phasic alertness, can the person react? Can they divide attention between visual and auditory attention, particularly when both are being
presented at the same time? Can you select what you need to attend to? Can you visually scan? And I am actually missing
an area of the screen, and I recall, when I was
doing testing of inpatients, that you might ask a
person to draw a clock face or perhaps a bicycle, and you
pay attention to how detailed was one side of the
picture versus the other, where they glossing over certain features? Was it kind of there but vague? Or was it just not seen at all? And I haven’t forgotten the time when a patient came in to see me who had shaved on one half of their face because they just didn’t
seem to see the other half. So that’s an area that
certainly we can screen for. When you look at verbal learning ability, is the patient able to
recognize recurring figures? Can they read and store words? Can they hold on to that information? And can they identify regularities? Can they see a series and
draw conclusions about that? And can they also look at
different parts of a visual field, keep their mind on what they’re doing, and answer the question. So those are some of those modules. Now, let me walk you through this. Once the patient has done the screening, this is the results. So the first thing to note is that you’re going to get a bar graph and it’s going to be
superimposed on scores. So right here, this is the normal area, let’s see if I can use something to identify that, here we go. Let’s do, how about purple? Will that do? And so here is normal. Let’s find another one
that actually shows up. Let’s do the laser pointer,
there we go, right here. That’s normal, all the way down, and this would be above average. Now, how far away from normal is it? Well, here’s one that goes
all the way down here. So you can see it’s color-coded. So in the green area, it’s up to one standard deviation below, so for a T-score, that’s from 50 to 40, but if it’s two standard deviations, we go down to 30 and then down to 20 and even lower than that. So here’s a person, who in a working speed
spatial number search task, is having major problems with
their speeded performance, here and also here. So this is way below where he should be, this is the normal starting point. Now, spatial number search
for sustained attention is within the normal range here, and here’s the evidence
of neglect or hemianopsia, is the particular blindness
on the right or left side? Again, it’s going to be
slightly out of the range, so these are color coded and numerical, and what we can say is that you can have scores that will characterize
that person’s performance with percentiles, Z-scores, P-scores, to help you figure it out. In addition to that, we can look at the
different training modules that may be recommended. This person’s really having a problem, therefore, attention
concentration in parentheses or in brackets is suggested in some cases. And then, a discussion. The results are summarized
to the left of the graph, and when you start off as having an average or normal sample, it is color coded. So red would show this
patient’s performance is more than three standard
deviations below the norm, so that’s not good. So we can see the details, you can print this if you wish, you can export it, you
can also close out of it. And the gray bars denote deviations from the norm. So once we’ve screened, there are training modules
that you can then get into. Attention is implicated in
a large number of disorders of patients that we see,
perhaps as many as 80%, after a CVA or acquired brain injury, may have an attention problem. So we know it’s pervasive and we know that it may present with other disorders. So what the computer might do is say this patient should start
with selective attention here, there are 24 different levels, here’s a recommended starting point. Now, if it’s too hard, you can go to a much easier module. So you can then ask the patient
to do alertness training and perhaps vigilance training. So is the person able to react? Are they responding? Are they sustaining vigilance? So once you’ve accomplished those, you may find that you can then move back into selective attention. If it’s too hard, make it easy. However, if it’s too
easy when you start here, you can do more challenging
ones, such as here. You can do visual spatial attention, or spatial perceptual,
or divided attention, and these are really quite
challenging down here. So this area here is more challenging, this area is more easy, and the computer might recommend
this is a starting point and you can then see
where do I go from here. So here’s an example. This is level six, you can see that here, and what we have to do is
match to this stimulus here. So which one of these is like this? And so when you say to the patient, I want you to start here, this is level six, it goes
all the way down to level one, and in some cases, it may
even go on to level 23. If it’s too hard, go back to
an easy one, an easier level. If this is too easy, you can
go on to a much harder one, but you can also stay with this and see if the patient
can get 100% correct. So you can escape to change
the level of difficulty. It’s up to you, you’re
the clinician, you decide. Now, for the easier modules, there are some that look
at reaction behavior. Do you respond? Can you keep your mind on what
you’re supposed to be doing as these are moving along? Then, you can look at spatial attention, for spatial operations,
two-dimensional operations, and three-dimensional operations, and then the more
challenging ones are here, driving a train and driving
a car, and as you can see, you have to regulate your speed in accordance with posted speed signs and you may also
find that there’s a cop car in your rearview mirror
and you need to decide whether you need to go
slower in order to comply with posted speed or whether
you need to go faster because you’re going too slowly. So the question is can
you take into account those different features
in your visual environment and monitor your performance? This, by the way, is one of the more popular tasks in Germany,
and as you can imagine, with a number of different patients wanting to resume driving, this may be one area that can be conducted to determine what their
reaction time is like and if they can take into account such things as visual field, and can they attend and
sustain attention over time? When you think about should
this patient be driving, this is just one task
that you can refer to and it will help the patients show that they are making progress. Now this is not the only
tool they use, obviously, but when you have the equivalent of an interstate with a speed limit and
very, very powerful cars, it’s gonna be very important
for a new physician or clinician to make
sure that other drivers are confident and able to
be safe behind the wheel. One of the next areas is called memory, and we have these
different aspects of memory including working memory
that has a lot of different components to it, different levels, topological, physiognomic, and so forth, and let’s get on with this. And you can see here’s working memory, can you remember the
cards and where they were? Can you remember those
picture cards and shapes? And can you remember faces? Interesting thing about physiognomy is can the person remember the names, occupations, and phone numbers, and when patients really have a problem recognizing, let’s say family members, or their own doctors and nursing staff, you can actually incorporate
some of those faces into the program. Figures, words, stories, particularly
with multiple choice, are all included. In the area of executive function, can the patient plan, reason, and make decisions about the functioning that will be important for them
to attend to daily routines in their normal life. So these are considered to
be more ecologically valid and meaningful to patients. So if they’re planning a vacation, what are the parts of it that
they need to pay attention to? And then if they’re
planning to go shopping, what do they need and in what order are they going to get things? And do they forget what
they went out shopping for? So these are areas that
may be very important and the patients can.

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